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Tumors of the stomach and duodenum. INTRODUCTION - STOMACH Benign Polyps – Hyperplastic – Fundic gland – Neoplastic – Multiple Tumors – Leiomyomas – Lipomas.

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Presentation on theme: "Tumors of the stomach and duodenum. INTRODUCTION - STOMACH Benign Polyps – Hyperplastic – Fundic gland – Neoplastic – Multiple Tumors – Leiomyomas – Lipomas."— Presentation transcript:

1 Tumors of the stomach and duodenum

2 INTRODUCTION - STOMACH Benign Polyps – Hyperplastic – Fundic gland – Neoplastic – Multiple Tumors – Leiomyomas – Lipomas – Heterotopic pancreas Malignant Tumors – Carcinoma – Lymphoma – Sarcoma – Carcinoid Others Menetriers Disease Bezoar Volvulus

3 GASTRIC POLYPS Hyperplastic polyps – Most common type of polyp (65 – 90%) – Inflammatory or regenerative polyps In reaction to chronic inflammation or regenerative hyperplasia Often found in HP infections – Sessile and seldom pedunculated Mostly in the antrum Multiple in 50% of cases Varying in size but seldom < 2cm – Rate of malignant transformation 1 – 3% Usually larger than 2 cm

4 GASTRIC POLYPS Fundic Gland – Small elisions in the fundus Hyperplasia of the normal fundic glands – Often associated with FAP Therefore important as a marker for disease elsewhere in the GIT tract

5 GASTRIC POLYPS Neoplastic polyps – Types Tubular Villous (often larger - > 2cm - and malignant) – Macroscopically More often in antrum Pedunculated with malignant potential Solitary, large and ulcerated – Treatment Endoscopic removal if no malignancy identified with surveillance Excision with malignant focus or where endoscopic removal failed

6 GASTRIC POLYPS Multiple gastric polyps – Rare condition Adenomatous and hyperplastic polyps 20% incidence f adenocarcinoma – Treatment If confined to corpus and antrum – distal gastrectomy Otherwise total gastrectomy – Sometimes associated with Polyposis syndromes FAP Gardner Peutz-Jeghers Cowden Cronkhite Canada

7 GASTRIC LEIOMYOMA Incidence of 16% at autopsy Pathology – Arise from smooth muscle of the GIT tract Difficult to distinguish from GIST – 75% benign Differentiation only on mitotic index – Large protruding elisions with central ulcer Usually presents with bleeding if at all Treatment is local excision with 2 – 3cm margin

8 GASTRIC LIPOMA Rare subcutaneous lesions – Asymptomatic – On routine endoscopy – Require no treatment Pillow sign

9 HETEROTOPIC PANCREAS Ectopic pancreas – Most common found in stomach Within 6 cm from the pylorus – Also in Meckl’s diverticulum Rarely larger than 4 cm – Sessile and rubbery – Submucosal in location – Histological identical to normal pancreas

10 ADENOCARCINOMA OF THE STOMACH Declining incidence in western world – HP associated due to chronic atrophic gastritis – Also related to Low dietary intake vegetables and fruit High dietary intake of starches More common in males ( 3 : 1 ) Histology – Invariably adeno-carcinoma – Squamous cell carcinoma from oesophagus Involves fundus and cardia

11 ADENOCARCINOMA OF THE STOMACH Histological typing – Ulcerated carcinoma (25%) Deep penetrated ulcer with shallow edges Usually through all layers of the stomach – Polipoid carcinoma (25%) Intraluminal tumors, large in size Late metastasis – Superficial spreading carcinomas (15%) Confinement to mucosa and sub-mucosa Metastasis 30% at time of diagnosis Better prognosis stage for stage

12 ADENOCARCINOMA OF THE STOMACH Histological typing – Linitis plastica (10%) Varity of SS but involves all layers of the stomach Early spread with poor prognosis – Advanced carcinoma (35%) Partly within and outside the stomach Represents advanced stage of most of the fore mentioned carcinomas

13 ADENOCARCINOMA OF THE STOMACH Symptoms and signs – Vague discomfort difficult to distinguish from dyspepsia – Anorexia Meat aversion Pronounced weight loss – At late stage Epigastric mass Haematemesis usually coffee ground seldom severe – Metastasis Vircho node in neck Blumer shelf in rectum

14 ADENOCARCINOMA OF THE STOMACH Surgical resection only cure – Late presentation makes sugary often futile – Palliation controversial for Haemorrhage Gastric outlet – Simple gastrectomy as effective as abdominal block Splenectomy often added due to direct involvement Only for the very distal partial gestrectomy Rest total gastrectomy Prognosis overall 12% 5 year survival – 90% for stage I disease


16 GASTRIC LYMPHOMA 5% of all primary gastric neoplasm's 2 different types of lymphoma – Part of systemic lymphoma with gastric involvement (32%) – Part of primary involvement of the GIT (MALT Tumors) 10 – 20% of all lymphomas occur in the abdomen 50% of those are gastric in nature Risk factors – HP due to chronic stimulation of the MALT – In early stages of disease Rx of HP leads to regression of the disease

17 GASTRIC LYMPHOMA Primary MALT Early stages also referred to as pseudo-lymphoma – Indolent for long periods – Low incidence of Spread to lymph nodes Involvement of bone marrow – Therefore much better prognosis Mostly involves the antrum 5 different types according to appearance – Infiltrative- Ulcerative – Nodular- Polypoid – Combination

18 GASTRIC LYMPHOMA Primary MALT At time of presentation – Larger than 10 cm (50%) – More than 1 focus (25%) – Ulcerated (30 – 50%) Pattern of metastasis similar to gastric carcinoma Signs and symptoms – Occur late and are vague – Relieved by anti-secretory drugs – Diagnosis based on histology

19 GASTRIC LYMPHOMA Primary MALT Treatment controversial – Surgical treatment for patients without systemic involvement Mandatory for high grade lesions Possible not needed for low grade lesions Total gastrectomy and en-block for direct involvement – Sparing duodenum and oesophagus – Palliative resection with intra-abdominal spread Good for bleeding, obstruction and perforations – Radiation and chemotherapy combination for most

20 GASTRIC SARCOMA 1 – 3 % of gastric malignancies Include a wide variety of tumors – Leiomyosarcoma – Leiomyoblastoma – GIST

21 MENETRIERS DISEASE Giant gastric folds (hypertrophic gastropathy) Differentiate from – Infiltrating neoplasm (Ca / lymphoma) – CMV infection Manifestation – Hypo-proteinaemia due to loss from ruggae – Chronic blood loss Treatment – Medical (PPI, atropine, H2 blockers) – Surgical for refractory cases or where Ca cant be excluded

22 GASTRIC BEZOAR Concretions in the stomach – Tricho-bezoar (hair) Young girls who pick and swallow their hair – Phyto-bezoar (vegetable fibre) Can cause erosions and bleeding – Seldom perforate but if mortality 20% Post-gastrectomy predisposes – Both mechanical and chemical Endoscopic breakage

23 GASTRIC VOLUVLUS 2 Types – Organo-axial Through the organs longitudinal axis More common and associated with hiatus hernia Eventration of the diaphragm – Mesenterio-axial Line through mid lesser to mid greater curvature Clinical triade (Brochardt’s) – Vomiting followed by retching and inability to vomit – Epigastric distension – Inability to pass NGT

24 GASTRIC VOLVULUS Treatment – Emergency surgery as any volvulus

25 GASTRIC DIVERTICULAE True diverticulae uncommon – Involve all layers of the wall – Pre-pyloric in location Pulsion with only mucosa and sub-mucosa – Within a few cm of GEJ Asymptomatic found on routine investigations – Confused with peptic ulceration

26 INTODUCTION - DUODENUM Benign Brunners gland adenoma Leiomyoma Carcinoid Heterotopic gastric mucosa Villous adenoma Malignant Peri-ampullar adeno CA – Duodenum – Cholangio – Pancreatic head Leiomyosarcomas Lymphomas Others Duodenal dIverticula

27 DUODENUM Benign tumors Brunners gland adenomas – Small submucosal Sessile and pedunculated variants – Posterior wall junction D1 and D2 – Symptoms due to bleeding or onstruction Leiomyoma – Asymptomatic Carcinoid – Mostly active (gastrin, SS and serotonin) – Simple excision

28 DUODENUM Benign tumors Hetrotopic gastric mucosa – Multiple small mucosal lesions – No clinical significance Villous adenoma – Intestinal bleeding – Obstruction of ampulla with jaundice – Risk of malignancy high (50%) – Endoscopic snaring or local excision

29 DUODENUM Malignant tumors Located in the descending part of the duodenum Symptoms – Pain, obstruction bleeding and jaundice – Earlier than pancreas head Treatment – Pancreatico-duodenectomy for localized lesions Much better prognosis than pancreas Ca (30% 5-year as opposed to 0%) – Palliative bypass procedures if not resectable – Radiotherapy for advanced disease ?

30 DUODENAL DIVERTICULAE Incidence – 20% at autopsy – 5 – 10% at upper GIT investigations Pulsion diverticulae – 90% on the medial border of the duodenum – Solitary and within 2.5 cm of the ampulla – Associated gallstones and gallbladder disease Pseudo-diverticluae – First part of the duodenum – Scarring of PUD

31 DUODENAL DIVERTICULAE Presentation – Chronic post-prandial pain and dyspepsia With complicated disease – Bleeding and perforation – Panceatitis – Jaundice Surgery for complicated disease – Dissection, removal and closure (even with perforation) – With billiary involvement : cholidocho-duodenostomy

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